Endovascular stenting in neoplastic superior vena cava syndrome prior to chemotherapy or radiotherapy.

BACKGROUND: The standard conventional palliative treatment of choice for patients with neoplastic superior vena cava syndrome (SVCS) is chemotherapy, radiotherapy or surgery. In our study, palliative stenting was used as a first-line therapeutic measure in all cases using self-expanding stents prior to any antitumour therapy. METHODS: 17 patients, 10 men and 7 women, all of whom presenting with the clinical diagnosis of SVCS confirmed by phlebography combined with CT, were referred for stenting of the superior caval vein. All procedures were performed after local anaesthesia without sedatives or general anaesthesia in the angiosuite at the radiology department. Symptom response was evaluated directly after the procedure at several intervals by clinical and nursing staff. RESULTS: 19 self-expanding Symphony stents were successfully implanted in 15 of 17 cancer patients with SVCS in a period of five years. All 15 individuals remained free from SVCS after the successful stenting procedure. No stent-related complications occurred. CONCLUSION: This study demonstrates that palliative SVC stenting prior to any antitumour therapy is feasible, easily performed without serious complications and provides a quicker symptom response than obtained with radiation therapy or chemotherapy alone. Primary stenting also provides the opportunity to establish a correct diagnosis before starting antitumour therapy.

Epithelioid haemangioendothelioma of the lung: clinical and pathological pitfalls.

In 1973, a 10 year old boy presented with numerous bilateral lung nodules, diagnosed as histiocytosis X by open lung biopsy. The patient was treated with prednisone until 1984. In 1993, he developed severe pain in the neck. A biopsy of the spine revealed the same tumour morphology as was seen in the lung in 1973. Immunohistological examination of the former and present biopsy led to the definitive diagnosis of epithelioid haemangioendothelioma of the lung with metastases to spine and liver. Epithelioid haemangioendothelioma of the lung is a rare soft tissue tumour of vascular origin, readily mistaken for carcinoma or, as in this case, histiocytosis. The tumour has an intermediate malignant potential. Although metastases of epithelioid haemangioendothelioma of the lung are well-known, metastatic spread to bones, as in our case, has not previously been mentioned in the literature.

Chronic obstructive pulmonary disease and abdominal aortic aneurysms.

In a prospective study during the period January-May 1992, 362 consecutive out-patients above 65 years of age, attending the pulmonary department for chronic obstructive airways disease (COPD), were ultrasonographically screened for an aneurysm of the abdominal aorta (AAA). Data from pulmonary function tests together with history of cardiac disease, diabetes mellitus, hypertension, hypercholesterolaemia, peripheral arterial obstructive disease, smoking and corticosteroid medication were collected. 30/282 men and 6/80 women with COPD had an AAA > or = 30 mm in diameter, which equals a prevalence of 9.9% (95% confidence limits: 6.8-13.0%). COPD patients with severe emphysema, having a decreased forced expiratory volume/vital capacity ratio (FEV/VC) of < 55%, have a significantly higher prevalence of aortic dilatation or AAA compared to COPD patients with mild or moderate decreased FEV/VC (chi-squared test: p < 0.05, alpha = 0.05). In the group of patients with AAA, significantly more smokers were seen compared to the group with normal and dilated aortas (chi-squared test: p < 0.05).

Comparison of two carboplatin-containing regimens with standard chemotherapy for small cell lung cancer in a randomised phase II study. The EORTC Lung Cancer Cooperative group.

The EORTC Lung Cancer Cooperative group performed a randomised phase II study in patients with small cell lung cancer comparing the standard cyclophosphamide/doxorubicin/etoposide (CDE) regimen with two regimens containing the new and active cisplatin derivative, carboplatin, 400 mg/m2 in combination with ifosfamide, a drug without important myelotoxicity, at a dose of 5 g/m2 (IMP) or the non-myelotoxic drug vincristine twice 2 mg (VP). Of 178 evaluable patients, 63 received CDE [30 limited disease (LD), 33 extensive disease (ED)], 55 received IMP (22 LD, 33 ED) and 60 (26 LD, 34 ED) were treated with VP. The response duration was not statistically different: CDE 31 weeks, IMP 29 weeks and VP 21 weeks. The time to progression after CEE was 28 weeks, IMP 24 weeks and VP 17 weeks. This was significantly shorter after VP than after CDE (P = 0.017). The 60% response rate of the VP combination was low compared with CDE (83%) and IMP (77%). Toxicity of all three regimens was acceptable, and dose reduction for myelosuppression was necessary in only a minority of the patients. We conclude from this study that the combination of carboplatin, at the maximally tolerated dose of 400 mg/m2, in combination with ifosfamide 5 g/m2, is an active regimen with efficacy comparable with the standard CDE regimen.

[Spontaneous pneumothorax; to operate or not?]. / De spontane pneumothorax; opereren of niet?

Disagreement remains on the best mode of therapy for spontaneous pneumothorax (SP). Treatment options vary from observation alone to thoracotomy depending on the stage of the disease and the preference of the physician. Between 1983 and 1988, 122 patients with SP were treated at the Elisabeth Hospital Tilburg according to a fixed protocol. Of these patients 86 (68%) were primarily treated with observation alone or with intercostal tubes. Seven of these patients (8%) had to be treated surgically after failure of the primary treatment. After thoracoscopical selection and in case of recurrent disease 39 patients underwent surgery: apical pleurectomy and bullectomy, in most cases by the transaxillary approach. In this group morbidity was minimal and there were no recurrences. We conclude that for most patients with spontaneous pneumothorax non-surgical therapy is the therapy of first choice.

[Examination of the mediastinum in staging of primary bronchial carcinoma]. / Onderzoek van het mediastinum bij de stadiëring van het primaire bronchuscarcinoom.

Mediastinoscopy and CT are used to evaluate the mediastinum in patients with non small cell lung cancer to determine operability. Generally, the sensitivity and negative predictive value of CT are high, in a personal study in 150 patients 86% and 92%, respectively. When CT does not reveal enlarged lymph nodes, we recommend thoracotomy without mediastinoscopy. However, micrometastases in non-enlarged lymph nodes will be missed. All positive CT scans necessitate mediastinoscopy, because enlarged lymph nodes frequently are not invaded with tumour (in our study in 33%). CT used in this way will increase the percentage of positive results of mediastinoscopy. In patients with a peripheral tumour lymphogenic spread to the mediastinum is not uncommon (in our study in 22%) and mediastinal evaluation should not be omitted. In these patients mediastinoscopy is also of diagnostic value.

Sustained-release theophylline preparations. A comparative survey of 467 patients.

The comparative efficacy and patient compliance with treatment using three sustained-release theophylline preparations currently available in The Netherlands were evaluated by measuring the plasma concentration achieved in a survey of 282 hospital and 185 out-patients. Compliance was dramatically better amongst in-patients than those attending out-patient clinics. Complete treatment avoidance was higher than expected. Compliance was better among non-smokers than among patients who were still smoking. Patients clearly preferred preparations which permitted a simple daily dosing schedule requiring the minimum number of tablets. On this basis and that of the parameters measured, Theolair Retard was the preparation of choice. Plasma concentration should be monitored during long-term theophylline treatment.

Antigen bronchial challenge and efficacy after 4 weeks of treatment with ketotifen and disodium cromoglycate.

Oral ketotifen (Zaditen) 1 mg twice daily was compared with inhaled disodium cromoglycate (DSCG; Lomudal) 20 mg four times a day in an open study with two matched groups of patients treated for protection against allergen-induced bronchoconstriction. 9 patients were treated with ketotifen and 9 patients with DSCG for 4 weeks. The comparison of the differences between the mean values at provocation, at the start of the study, and after a 4-week drug treatment shows that the drugs are equally effective on the forced expiratory volume at 1 s. Ketotifen is less effective on the vital capacity than DSCG. Patients' and investigator's assessment of tolerability and efficacy of the two therapies were similar. It is concluded that ketotifen is as effective as DSCG in protecting asthmatic patients antigen bronchial challenge and is tolerated as well as DSCG.